NANDA Definition: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources

For most persons, everyday life includes its share of stressors and demands, ranging from family, work, and professional role responsibilities to major life events such as divorce, illness, and the death of loved ones. How one responds to such stressors depends on the person’s coping resources. Such resources can include optimistic beliefs, social support networks, personal health and energy, problem-solving skills, and material resources. Sociocultural and religious factors may influence how people view and handle their problems. Some cultures may prefer privacy and avoid sharing their fears in public, even to health care providers. As resources become limited and problems become more acute, this strategy may prove ineffective. Vulnerable populations such as elderly patients, those in adverse socioeconomic situations, those with complex medical problems such as substance abuse, or those who find themselves suddenly physically challenged may not have the resources or skills to cope with their acute or chronic stressors.

Such problems can occur in any setting (e.g., during hospitalization for an acute event, in the home or rehabilitation environment as a result of chronic illness, or in response to another threat or loss).

* Assess for presence of defining characteristics. Behavioral and physiological responses to stress can be varied and provide clues to the level of coping difficulty. * Assess specific stressors. Accurate appraisal can facilitate development of appropriate coping strategies. Because a patient has an altered health status does not mean the coping difficulties he or she exhibits are only (if at all) related to that. * Assess available or useful past and present coping mechanisms. Successful adjustment is influenced by previous coping success. Patients with history of maladaptive coping may need additional resources. Likewise, previously successful coping skills may be inadequate in the present situation. * Evaluate resources and support systems available to patient. Patients may have support in one setting, such as during hospitalization, yet be discharged home without sufficient support for effective coping. Resources may include significant others, health care providers such as home health nurses, community resources, and spiritual counseling. * Assess level of understanding and readiness to learn needed lifestyle changes. Appropriate problem solving requires accurate information and understanding of options. Often patients who are ineffectively coping are unable to hear or assimilate needed information. * Assess decision-making and problem-solving abilities. Patients may feel that the threat is greater than their resources to handle it and feel a loss of control over solving the threat or problem.

Therapeutic Interventions

* Establish a working relationship with patient through continuity of care. An ongoing relationship establishes trust, reduces the feeling of isolation, and may facilitate coping. * Provide opportunities to express concerns, fears, feelings, and expectations. Verbalization of actual or perceived threats can help reduce anxiety. * Convey feelings of acceptance and understanding. Avoid false reassurances. * Encourage patient to identify own strengths and abilities. During crises, patients may not be able to recognize their strengths. Fostering awareness can expedite use of these strengths. * Assist patient to evaluate situation and own accomplishments accurately. * Explore attitudes and feelings about required lifestyle changes. * Encourage patient to seek information that increases coping skills. Patients who are not coping well may need more guidance initially. * Provide information the patient wants and needs. Do not provide more than patient can handle. Patients who are coping ineffectively have reduced ability to assimilate information. * Encourage patient to set realistic goals. This helps patient gain control over the situation. Guiding the patient to view the situation in smaller parts may make the problem more manageable. * Assist patient to problem solve in a constructive manner. * Discourage decision making when under severe stress. * Reduce stimuli in environment that could be misinterpreted as threatening. This is especially common in the acute hospital setting where patients are exposed to new equipment and environments. * Provide outlets that foster feelings of personal achievement and self-esteem. Opportunities to role play or rehearse appropriate actions can increase confidence for behavior in actual situation. * Point out signs of positive progress or change. Patients who are coping ineffectively may not be able to assess progress. * Encourage patient to communicate feelings with significant others. Unexpressed feelings can increase stress. * Point out maladaptive behaviors. This helps patient focus on more appropriate strategies. * Administer tranquilizer, sedative as ordered. These facilitate ability to cope. * Assist to grieve and work through the losses of chronic illness and change in body function if appropriate.

Education/Continuity of Care

* Instruct in need for adequate rest and balanced diet. These facilitate coping strengths. Inadequate diet and fatigue can themselves be stressors. * Teach use of relaxation, exercise, and diversional activities as methods to cope with stress. * Involve social services, psychiatric liaison, and pastoral care for additional and ongoing support resources. * Assist in development of alternative support system. Encourage participation in self-help groups as available. Relationships with persons with common interests and goals can be beneficial.